脑梗死临床护理路径

脑梗死临床护理路径

Clinical XXX

1.Acute Phase XXX

Nursing Pathway:

1.XXX.

2.Provide level I XXX.

3.XXX.

4.Provide dietary guidance.

5.Assist XXX.

Nursing ns:

1.Conduct n nursing assessment.

2.Monitor vital signs upon n: temperature。pulse。n。and blood pressure.

3.Introduce the hospital environment。ns。director。head nurse。attending physician。XXX items。prohibit smoking。

sign a two-way commitment letter。inform patients of hospital rules and ns。and introduce ward facilities and their usage.

4.XXX measures。XXX。trimming nails。shaving beards。and bathing.

municate with patients to alleviate fear。stabilize ns。XXX with treatment。Train patients on how to XXX.

6.Provide dietary guidance: low-salt。low-fat。low-cholesterol。moderate sugar。and rich in vitamins.

7.Instruct patients on how to n the affected XXX post-thrombolysis ns。n treatment principles。drug effects。and side effects.

8.Monitor patient n。observe symptoms such as dizziness。nausea。vomiting。slurred speech。and limb paralysis。and assess sleep quality at night.

9.Before the re: (1) alleviate fear。stabilize ns。and XXX with treatment。Train patients on how to XXX(2) XXX(3) Closely observe changes in usness。mental status。XXX(4) Notify the physician of XXX(5) Record XXX.

After the re: (1) Observe changes in the patient's n。provide symptom care。XXX(2) Check blood cell n。(3) XXX.

2.Non-Acute Phase

Nursing Pathway:

1.XXX.

2.Assist XXX。cervical artery color Doppler ultrasound。and blood tests.

3.XXX XXX。n。antiplatelet n。XXX.

4.Provide level I XXX.

Nursing ns:

1.Monitor vital signs: temperature。pulse。n。and blood pressure.

2.Provide a proper sleeping n: raise the bed head 15-30 degrees and XXX.

3.Provide dietary guidance: XXX on low-salt。low-fat。low-cholesterol。moderate sugar。and rich in vitamins.

4.Observe n ns: ce the frequency of invasive ns。and apply pressure for a longer time after XXX.

5.Observe for XXX: XXX.

6.XXX。and encourage patients to do so.

3.n Days 1-3

Nursing Pathway:

1.XXX.

2.XXX XXX。n。antiplatelet n。XXX.

Nursing ns:

1.Monitor vital signs: temperature。pulse。n。and blood pressure.

2.Observe for XXX: XXX.

3.Record XXX.

1、按照医嘱和护理常规进行护理。

2、使用脱水、抗凝、抗血小板聚集、促脑代谢药物。

3、对于需要脱水的患者，应该复查电解质。

4、指导患者正确进行患肢功能位摆放，并进行床上体位的变换和移动训练，根据病情加重程度适当增加活动次数。

5、向患者详细讲解早期康复的重要性，并要求患者积极配合康复训练。

护理路径：

1、执行神经内科护理常规。

2、遵循医嘱进行药物治疗。

3、协助患者进行血液检查，如果没有出血倾向，应继续降纤治疗。

4、根据患者的体温、脉搏、呼吸、血压进行监测。

5、观察是否有出血点和黑便等出血倾向。

6、评估皮肤和排泄情况，尽量解除留置尿管。

7、给予患者弹力袜，并向其讲解其重要性。

8、进行床上被动康复训练，并向患者讲解其重要性。

护理路径：

1、按照医嘱和护理常规进行护理。

2、使用脱水、抗凝、抗血小板聚集、促脑代谢药物。

3、视情况酌情复查血常规、血细胞凝集、生化、二便。

4、根据患者的体温、脉搏、呼吸、血压进行监测。

5、观察病情，给予相应的护理。

6、介绍翻身的方法并教会家属。

7、介绍吞咽功能的锻炼方法。